Visual Diagnosis
Rakesh D. Mistry, MD, MS
Division of Emergency Medicine
Children’s Hospital of Philadelphia
1
8 mo. with fever and diaper rash
2
8 mo. with fever and diaper rash
Differential Diagnosis
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Bullous impetigo
S. aureus scalded skin
Erysipelas
Perianal group A strep
Stevens-Johnson
Partial-thickness burn
3
Erysipelas
4
10 y.o. male with rash on leg
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Ecthyma
• Local necrotizing skin
infection
• Microbiology
– Streptococcus pyogenes
(GABHS)
– S. aureus
– Pseudomonas aeurginosa
• Systemic
– Ecthyma gangrenosa
– Immune deficiency
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Ecthyma
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Bullous impetigo
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4 y.o. girl with progressive facial
swelling and fever
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Facial Swelling
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Dental abscess
Facial cellulitis
Parotitis
Sinusitis
Lymphadenitis
Insect bite
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Another view…
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Facial Cellulitis
• Microbiology
– Staphylococcus aureus
– Group A ß-hemolytic Streptococcus (GABHS)
– Haemophilus tnfluenzae type B
• Treatment:
– Cephalosporins, clindamycin
– Consider IV
12
6 y.o. male with fever, neck
swelling, pain with eating
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Parotitis
• Displaces ear
• Obscures inferior border
and angle of mandible
• Microbiology
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S. aureus
Oral flora
Infuenzae
Coxsackie/Enteroviruses
Mumps
HIV
• Consider imaging for
abscess
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Lymphadenitis
• Microbiology
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GABHS
H. influenzae
S. aureus
Oral flora
• Treatment
– Ampicillin/Sulbactam
– Clindamycin
– Consider imaging for
abscess
15
12 mo. female with “rash”
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Popsicle Panniculitis
• Extended contact with cold
• Subcutaneous fat necrosis
• Benign condition: Reassurance
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5 y.o. girl with blood in
underwear
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Urethral Prolapse
• Pre-pubertal girls
• Associated with constipation, increased abdominal
pressure
• Management
– Sitz baths and reassurance
– Topical estrogen cream
– Urology follow-up
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13 y.o female with 6 months of
episodic abdominal pain
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Hematocolpos
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Imperforate hymen
Primary amenorrhea
Abdominal mass
Treatment: Surgical
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Electrical Burn
• Differential
– Caustic ingestion
– Infectious
• Risk for delayed labial artery bleed
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15 y.o. fever, sore throat,
abdominal pain
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15 y.o. fever, sore throat,
abdominal pain
• Differential Diagnosis
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GABHS
N. gonorrhea
Adenovirus
Influenza
Mononucleosis
• Diagnosed
GABHS (+)
• Placed on penicillin
• Epstien-Barr Virus
(EBV)
• Cytolomegalovirus
(CMV)
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Non-compliant…Returns in 5 days
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Peritonsillar Abscess
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Older children and adolescents
“Hot-potato” voice
Trismus and drooling
Management
– Needle aspiration
– Antibiotic therapy
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14 y.o. male with fever, neck
pain, and dysphagia
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Ludwig’s Angina
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Ludwig’s Angina
• Submandibular/sublingual infection
• Rapidly progressive
• Management
– Monitor airway
– IV antibiotics
– Surgical drainage
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18 mo. “not using hands”
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18 mo. “not using hands”
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Vitamin D Deficiency
• Hypocalcemia
• Dietary
• Skeletal findings
– Bowing
– Epiphyseal widening
– “Rachitic rosary”
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3 y.o. girl not using right arm
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Radial Head Subluxation
• Typical appearance of well-appearing child
not using affected arm
• Reduction
– Supination-Flexion
– Pronation-Extension
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8 y.o. female with fatigue and
dyspnea on exertion for 2 weeks
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Pallor
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Anemia
• Typically appears with
hemoglobin ~8 gm/dL
• Anemia
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Nutritional
Blood loss
Malignancy
RBC destruction
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Infant with severe diarrhea
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Central Cyanosis
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Severe pulmonary disease
Shock
R L cardiac shunt
Polycythemia
Abnormal hemoglobin states
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Methemoglobinemia
• Oxidative stress: diarrhea,
dehydration, acidosis
• Methemogobin cannot
carry O2  tissue hypoxia
• Fluid resucitation
• Methylene blue
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Fever and spreading rash
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Petechiae
• Meningococemia
• Viral exanthem
• Rocky Mountain Spotted Fever
(Rickettsia rickettsi)
• Immune Thrombocytopenic
Purpura
• Mechanical
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5 y.o. male casted 3 days ago for
presumed fracture, now with rash
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Henoch-Schonlein Purpura
• Presentation
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Palpable purpura
Joint swelling and pain
Abdominal Pain
Renal involvement
• Management
– Pain control
– Urinalysis
– Consider steroids
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Malar Rash: Systemic Lupus
Erythematosus (SLE)
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14 year old boy with painful rash
on face and eye pain
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Herpes Zoster
• Dermatomal
distribution
• Pain control
• IV or PO Acyclovir
• Trigeminal nerve:
suspect ocular disease
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3 y.o. with “finger infection”
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Herpetic Whitlow
• Differential Diagnosis
– Paronychia
– Bullous impetigo
• Do not incise
• Treat symptomatically
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2 y.o. history of dry skin, now red
painful rash
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Eczema Herpeticum
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3 y.o. girl with rash on face
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Herpes Keratoconjunctivitis
• Analgesia
• Topical Acyclovir
• Do not use steroids!
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21 mo.female with right eye
swelling and fever
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Eye Swelling
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Conjunctivitis
Periorbital cellultiis
Orbital cellulitis
Insect bite
Allergic reaction
Hypoproteinemia (Nephrotic Syndrome)
Epstien-Barr Virus
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Poked in eye at school
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Open Globe Injury
• Iris plugs defect misshapen pupil
• Stop examination immediately
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Cover eye with hard protective shield
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Consult ophthalmology
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Avoid increases in intraocular pressure
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No ointments or drops
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Neonate with fever and pus from
umbilical stump
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Omphalitis
Differential
• Infected urachal cyst
• Umbilical hernia
• Patent omphalomesenteric
duct
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4 y.o. backseat passenger in motor
vehicle crash
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Seatbelt/Lapbelt Injury
• Abdominal or pelvic bruising
• Intra-abdominal injuries
• Hollow viscus
• Solid organs
• Lumbar spine fracture (Chance fracture)
• Management
• Abdominal CT
• Admit for serial exams
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20 mo. male was “playing rough”
with brother
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Child Abuse
• Multiple bruises
• Soft tissues-not over
bony prominences
• Shape of fist or pinch
• Loop-belt or cord
marks
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3 week-old with eye swelling
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3 week-old with eye swelling
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Orbital Tumor
• Neuroblastoma
• Retinoblastoma (usually within globe)
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Ophthalmia Neonatorum
• Chlamydia trachomatis
• Neisseria gonhorrheae
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12 mo. female with rash
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12 mo. female with rash
• Differential Diagnosis
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Urticaria
Stevens-Johnson Syndrome
Erythema Migrans (Lyme Disease)
Erythema Multiforme
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Erythema Multiforme Minor
• Infectious
– Epstein-Barr Virus (EBV)
– Mycoplasma
• Serum sickness
• Autoimmune disease
• Malignancy
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Teenager with fever, rash, red eyes
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Teenager with fever, rash, red eyes
• Differential Diagnosis
– Adenovirus
– Kawasaki syndrome
– Stevens-Johnson
Syndrome
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Stevens-Johnson Syndrome
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Erythema multiforme major
Mucosal surfaces
Etiology: infections? medications?
Severe cases: exfoliating, similar to burn
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12 y.o. male with painful leg rash
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Erythema Nodosum
• Painful, wellcircumscribed nodules
• Etiology
– Infectious
– Medications
– Inflammatory bowel
disease
– Malignancy
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Uvular Swelling
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Allergic/angioedema
Infection (GABHS)
Trauma
Thermal or Chemical irritation
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Recurrent infection of outer ear
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The other ear…
• Pre-auricular sinus and
cyst
• Diagnosis
– Neonatal period
– Infection later in life
• Associated with
deafness
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8 y.o. fever, headache, vomiting
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8 y.o. fever, headache, vomiting
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Pott’s Puffy Tumor
• Sinusitis with:
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Scalp swelling
Osetomyelitis and anterior erosion
Extradural abscess
Intracrania abscess
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2 y.o. thigh pain and redness
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2 y.o. thigh pain and redness
• Differential Diagnosis
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Cellulitis
Skin abscess
Osteomyelitis with fistula
Retained foreign body
Spider bite
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Skin Abscess
• Methicillin-resistant S.
aureus (MRSA)
• Incision and drainage
paramount
• Clindamycin or
trimethoprim-sulfa
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Venomous Snake Bite
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Venomous Snake Bite
• Crotalinae family, or
“pit vipers”
– Vertical, elliptical pupils
– Triangular head
– Single row of caudal
plates, or rattle
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Venomous Snake Bite
• Immobilize
extremity below
heart
• NOT indicated
– Incision and suction
– Tourniquet
– Cryotherapy
• Anti-venin required
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10 y.o. girl with fever, left eye
pain, and diplopia
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Orbtal Myositis
• Pain
• Fever
• Ocular muscle
paresis
• Proptosis
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14 y.o. female with “uneven
smile” noted this AM
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Peripheral Facial Nerve Palsy
• Common etiologies
– Idiopathic (Bell’s Palsy)
– Borrelia burgdorferi
(Lyme Disease)
– Varicella-Zoster
(Ramsay Hunt Syndrome)
– Herpes Simplex Virus
– Epstein-Barr Virus (EBV)
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Peripheral Facial Nerve Palsy
• Treatment
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Fluoroscein eye
Eye patching and lubricant
Presence of Otitis media is ENT emergency!
Treat underlying condition if noted
Empiric steroids and acyclovir controversial
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